BACKGROUND: People who use heroin and crack cocaine today are older than in the past. The main causes of illness and death are shifting from infections and drug poisoning (the main health issues in this population in the 1980s and 1990s) to respiratory, cardiovascular, and other non-communicable diseases. Qualitative research has identified barriers to treatment of these conditions. However, research remains focused on preventing crime, drug overdoses, and transmission of blood-borne viruses. This thesis aims to understand the physical health needs of this population, with a focus on people using heroin and crack cocaine in England, and provide recommendations for more accessible healthcare.
METHODS: The thesis includes: (a) literature reviews relating to frequency of healthcare utilisation, access to healthcare for physical health problems, and interventions that aim to improve physical healthcare; (b) a qualitative study of clinicians working in community drug and alcohol services to understand how they perceive their role in physical healthcare; (c) a study of causes of death among people who use illicit opioids; (d) a case study of the burden and treatment of chronic obstructive pulmonary disease (COPD) among people who use illicit opioids.

RESULTS: The literature reviews found limited research into access to physical healthcare for people who use illicit drugs, or the effectiveness of interventions that aim to improve healthcare for this population. Existing studies focused on cancer screening participation in the United States, finding that illicit drug use was associated with lower uptake. The qualitative study found that clinicians working in community drug and alcohol services in the UK often take a ‘health advocate’ approach to help their clients get appointments with GPs and other health services. However, participants reported limited success, and many referrals end in non-attendance. Although participants said they were often the first point of contact for a wide range of health problems, they did not have the resources to respond to these needs and felt isolated from other health services. The study of mortality found that illicit opioid use was associated with greater risk of all causes of death, including respiratory diseases, cancers, cardiovascular diseases, infections, liver disease, and accidents. While the highest relative mortality risks were associated with drug poisoning and viral hepatitis, more excess deaths were caused by physical non-communicable diseases. At a population level, the increasing average age of people using drugs explains an increase in deaths due to non-communicable diseases, but not the recent increase in drug-related deaths. The case study of COPD found that a history of illicit opioids was associated with more severe disease at diagnosis, approximately double the risk of adverse outcomes such as acute exacerbations, but similar probability of treatments such as COPD-specific medications, immunisation against respiratory infections, and smoking cessation support.

CONCLUSION: The health needs of people who use heroin and crack cocaine are shifting toward physical non-communicable diseases. Services that support people who use heroin and crack cocaine are not equipped for this. The case study of COPD suggests that COPD-related inequalities are likely to be driven by exposures before diagnosis and later diagnosis, rather than access to care after diagnosis. This shows the need for more accessible primary care for this population and investment in primary prevention such as smoking cessation.

FUNDING: National Institute for Health Research